Basic Information
Provider Information | |||||||||
NPI: | 1740339464 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NETTER | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 230 5TH AVE | ||||||||
Address2: |   | ||||||||
City: | INDIALANTIC | ||||||||
State: | FL | ||||||||
PostalCode: | 329033176 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3219567530 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 12196 COUNTY ROAD 512 | ||||||||
Address2: |   | ||||||||
City: | FELLSMERE | ||||||||
State: | FL | ||||||||
PostalCode: | 329485463 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7722578224 | ||||||||
FaxNumber: | 7725718846 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/10/2007 | ||||||||
LastUpdateDate: | 09/11/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | ME33902 | FL | Y |   | Allopathic & Osteopathic Physicians | General Practice |   |
No ID Information.